HEPATITIS C and the fire service part 1: assessing the risk

The news that Philadelphia (PA) Fire Depart-ment (PFD) firefighters screened for hepatitis C (HCV) in 1999 had an infection rate almost three times the average for the U.S. population vividly reminded the fire service that complacency in the health and safety arena can be as deadly as complacency on the fireground. The revelation moved fire departments to look more closely at their infection-control policies and means for protecting their members against infectious diseases and supporting those who already have become infected.

THE PHILADELPHIA STORY

Paramedic Marcellus Hatcher, one of the first PFD members to be identified as having the HCV infection, died in 1998 while awaiting a liver transplant. The disease forced him to retire in 1997, and he ultimately ran out of sick leave. As the result of a court case fought and won by the Philadelphia International Association of Fire Fighters (IAFF) Local 22, the state of Pennsylvania awarded Hatcher’s widow his pension. At the time this article was being written (the middle of October), the Hatcher Case was the only HCV case that had been settled in Pennsylvania.

“It is very difficult,” says Stephen Hess, Local 22 public relations director. “You not only have to fight for your life, but you also have to fight with the city for your benefits, your good name, and your reputation at the same time. The city does everything it can in court to try to blame the victim for contracting the disease, even if the firefighter had no questionable lifestyle risks.”

Hatcher’s experience led Local 22 to look more closely at the hepatitis C issue. Subsequent prescreenings for a series of union-coordinated Red Cross blood donor drives showed that a significant number of Philadelphia fire and EMS workers were infected with HCV.

In November 1999, 2,146 current and retired Philadelphia firefighters were screened for hepatitis C using donated home test kits. Of this group, 97 (roughly five percent) were found to have the virus. As of July 30, 2000, 152 firefighters reportedly had the disease. According to union officials, however, more members have disclosed that they have the disease but do not want to make it public.

Treatment for this disease is costly, and the local has been finding it difficult to pay for the firefighters’ treatments. The city has rejected claims that the firefighters’ illness is related to their work. Philadelphia Mayor John F. Street, in January, had pledged to make $3 million available to help firefighters pay for costly medications. That money reportedly has been difficult to access, however.

“The union’s goal is to have hepatitis C declared presumptive in the case of emergency personnel, an in line-of-duty illness, thereby making afflicted firefighters eligible for workmen’s compensation benefits,” George T. Casey, a 32-year veteran of the Philadelphia Fire Department and president of Local 22, explained in an Open Letter to all Philadelphia firefighters and paramedics.

The local is also asking the city to extend retired firefighters’ health benefits until the age of 65 instead of having the benefits terminate four years after retirement. An individual who tests positive for hepatitis C may not even know he has it and may not experience any symptoms for 10, 20, or even 40 years, adds Local 22 Vice President Tom O’ Drain. That’s why, the union says, firefighters must have lifetime health care benefits. The IAFF is taking a closer look at retirees, according to George T. Burke, assistant to the president and director of public relations for the IAFF. “In many instances, we have lost track of our people; now, we will be monitoring them in terms of illnesses that may be related to the job that strike them later in life.”

To draw national attention to the seriousness of the first responder-hepatitis C problem, Local 22 hosted a rally/march in Philadelphia in August during the Republican National Convention. The event drew more than 1,400 (some reports put the attendance as high as 2,000) fire, ambulance, and rescue personnel predominantly from the East Coast. “There is an ignorance that surrounds this disease,” Hess says. “Firefighters and paramedics deserve the compassion of all levels of government.”

Among the speakers at the rally was Pennsylvania State Treasurer Barbara Hafer, a former public heath nurse. She called for comprehensive testing and better medical care for fire and rescue workers, whose jobs expose them to the illness. “The debate over infection rates should not be allowed to obscure the real issue,” she told the crowd. “Whatever the precise statistics may be, the fact is, thousands of fire and rescue workers suffer from hepatitis C because they are fire and rescue workers. Because they did what they had to do to save lives. Because they are heroes-no other reason.”

CDC REFUTES PHILADELPHIA FINDINGS

Responding to health agencies that had asked the Centers for Disease Control and Prevention (CDC) to investigate the Philadelphia HCV findings, the CDC ultimately released, in July 2000, “Hepatitis C Virus Infection Among Firefighters, Emergency Medical Technicians, and Paramedics-Selected Locations, United States, 1991-2000.” The report, part of the Morbidity Mortality Weekly Report, July 28, [49(29); 660-5], summarized studies the CDC had conducted among small samplings of firefighters from the Philadelphia, Atlanta (GA), Miami-Dade (FL), and Pittsburgh (PA) Fire Departments, and the state of Connecticut.

The CDC had concluded that although some of these workers may need HCV testing under certain circumstances, first responders are not at greater risk for HCV infection than the general population. Routine HCV testing, therefore, is not warranted, according to the CDC. First responders should continue to follow standard precautions to reduce workplace exposure to bloodborne pathogens.¹

Regarding the original Philadelphia firefighter test results, which the CDC termed incorrect, the CDC said that it had reanalyzed the serologic and questionnaire data from the 1999 Philadelphia study and determined that 64 (3.0 percent) of the 2,136 participants tested had positive readings. (The CDC firefighter figure was 10 fewer than the original Philadelphia study figure.) The highest prevalence (4.9 percent) was among men between the ages of 40 and 49.

According to the CDC, the 4.5 percent prevalence previously reported by Home AccessT (the agency that analyzed the blood samples of the Philadelphia firefighters) “was obtained by classifying as positive 20.6 percent of the serum samples not tested completely, in accordance with Food and Drug Administration (FDA) requirements.”

Also, the CDC report pointed out that although the overall prevalence of HCV infection among persons of both sexes over the age of five was 1.8 percent, the rate was 4.9 percent among men between the ages of 30 and 49-the group that represents most of the first responders in the CDC studies. Men between the ages of 40 and 59 currently would have the highest expected prevalence of infection.

Healthcare workers’ risk for acquiring HCV infection is low, the CDC says, “because HCV is not transmitted efficiently through occupational exposure.” According to the CDC, HCV infection among first responders was associated primarily with nonoccupational factors.

The CDC report noted the following findings pertaining to the other four regions covered:

Atlanta, Georgia. Of the 437 firefighters tested in May 2000 (from samples from a hepatitis B virus infection study among these subjects in 1991), nine (2.1 percent) were anti-HCV-positive; the highest prevalence (4.0 percent) was among men ages 35 to 39. HCV infection was not associated with duration of employment as a firefighter, occupational exposures to blood, history of blood transfusion, or illicit drug use; however, it was associated with a history of a sexually transmitted disease.
Connecticut. Among the 382 volunteer and paid firefighters and EMTs from whom serum samples were available, five (1.3 percent) tested anti-HCV-positive; prevalence was highest (2.6 percent) among men between the ages of 40 and 49. In 1992, the Connecticut Department of Public Health and Addiction Services had collected on a voluntary basis serum samples and demographic data from first responders in various regions of Connecticut for a study of immune response to the hepatitis B vaccine. These are the samples (anonymously) from which the CDC conducted its hepatitis C study in June 2000.
Miami-Dade County, Florida. Of the 1,314 participants tested between March and April 2000, 35 (2.7 percent) were anti-HCV-positive on the basis of EIA testing alone; 20 (1.5 percent) were confirmed positive for HCV through RNA testing. Prevalence of anti-HCV was highest (3.7 percent) among men over the age of 50. Increased risk for HCV infection was not associated with occupational exposures to blood, type of job (firefighter, EMT, or paramedic), or duration of employment as a first responder. Hep-C ALERT, a Florida-based patient advocacy organization, collaborating with University of Pittsburgh researchers, confidentially obtained the serum samples and information on occupational risk factors from Miami-Dade County municipal fire department personnel.

The serum samples were tested at a commercial laboratory.
Pittsburgh, Pennsylvania. Tests conducted during January and March 2000 revealed that five (3.2 percent) of the 154 respondents tested anti-HCV-positive; highest prevalence (5.2 percent) was among men between the ages of 40 and 49. Samples were tested for anti-HCV without supplemental or confirmatory testing. Anti-HCV positivity was not associated with occupational exposures to blood. University of Pittsburgh researchers had collected the serum samples and information on occupational exposures from paramedics working in Pittsburgh.

The CDC recommended the following: (1) Populations with a low prevalence of Hepatitis B (HBV) infection, including first responders, should not undergo routine HCV testing unless there is a history of an increased risk for infection, such as a blood transfusion before July 1992 or injecting for drug use. (2) For the purpose of postexposure management, first responders should be tested after a percutaneous or permucosal exposure to HCV-positive blood. Testing for these types of exposures could be considered when the HCV status of the source is unknown. (3) Standard precautions must be used to reduce workplace exposure to bloodborne pathogens. First responders should be educated about transmission of bloodborne pathogens, trained in proper safety measures, and provided with appropriate protective equipment. First responders also should be vaccinated against HBV and informed of protocols if percutaneous or permucosal exposures to blood occur.²

CDC-ACKNOWLEDGED LIMITATIONS

The CDC acknowledges that, “because of several limitations, the five studies summarized in the July report could not exclude the possibility that some first responders had acquired HCV infection from job-related exposures.” Examples of the limitations given were the following: (1) The sample size was small; the information on occupational (percutaneous, mucosal, or skin) exposures to blood was limited; and nonoccupational risk factors may have affected the evaluation of potential sources for infection. (2) The findings do not necessarily represent all first responders in the selected locations or the United States. (3) If first responders are less likely to have nonoccupational risk factors for HCV infection than the general population, then the expected prevalence in these workers might be lower.

The CDC has not studied firefighter or paramedic populations specifically.

REACTIONS TO THE CDC REPORT

Many in the fire and emergency medical services do not agree with the CDC’s position and say the agency’s statistics should be looked at more closely.

Philadelphia Fire Fighters Local 22 is demanding that the CDC declare its report on hepatitis C “null and void.” The union claims that the CDC study is flawed, the initial testing results are unreliable, and the CDC’s lack of controls makes the study inaccurate and unreliable.

The IAFF, in a letter dated September 15, 2000, to Donna Shalala, secretary of the U.S. Department of Health and Human Services, voiced strong objection to the report’s conclusions and recommendations. “We believe that the CDC’s conclusion that emergency response personnel are not at increased risk for Hepatitis C infection is scientifically flawed,” the letter states. “Moreover, their recommendation that emergency responder personnel not receive ‘baseline’ testing for Hepatitis C is misleading and will make it more difficult to determine when an infection is occupationally related.”

The letter also took exception to the CDC’s statement: “This report summarizes the findings of five studies of HCV infection among first responders.” This statement, the IAFF said, “is untrue and grossly misleading. Only two of the five ‘studies’ contain published data, and both of these efforts were developed and designed to assess issues related to Hepatitis B. The three remaining ‘studies’ represent unpublished data collected during what were primarily Hepatitis C education and screening programs. Data collected in an uncontrolled and scientifically flawed manner cannot simply be dubbed a ‘study’ by the CDC in order to confer validity ellipse.”

The CDC, the IAFF suggested to Shalala, “must undertake a more comprehensive review of this issue. The review should include scientists from NIOSH [National Institute for Occupational Safety and Health], who have a better understanding of occupational safety and health issues, and incorporate input from fire service personnel with expertise in occupational health and safety.”

“For the CDC to propose that firefighters/paramedics and EMTs in America are at no greater risk than the civilian population other than those that may practice hard-core drug addition is absolutely absurd and out of touch with reality,” says Jerry Smith, administrator of the Internet discussion forum, The Emergency Grapevine. The former Los Angeles City fire captain adds: “It’s beyond reasonable comprehension that a government agency could be so far removed from the real world.”

“The CDC’s report was not a ‘scientific investigation’; rather, it was a ‘review of the literature,'” observes Charles E. Truthan, DO, FACOFP, medical director of the Cascade Charter Township (MI) Fire Department and founder of Fire DocTM, P.C. and Fire Doc Services, Inc., which provide occupational health services for firefighters. In an e-mail message to Hess, Truthan confirmed that factors identified in the Philadelphia study are “significant,” including the higher infection rates in certain stations and among retirees and the lack of PPE prior to 1987. Truthan says the CDC report “opens more questions than it answers.” He questions the interpretation of the data analysis. Some unanswered questions he lists are the following: Is there a geographic difference in incidence and prevalence? Why is there an age difference? Did all first responder organizations institute “universal precautions” at the same time? If not, is there a difference between those departments’ prevalence of HCV? How “large” and how “repeated” does the ” ellipse large or repeated direct ellipse exposure to blood” have to be? Most importantly, what about those (31) Philadelphia firefighters that the CDC excluded from use as a “positive” screen? Have they been given the required additional evaluation testing? If not, why not?

He says some bad assumptions have been made regarding risk factors as the etiology of a disease. Using unpublished data [Third National Health and Nutrition Examination Survey 1988-1994 (NHANES III)] as a basis of reference is questionable from a scientific standpoint. This unpublished CDC study was used to establish a national HCV prevalence rate of 1.8 percent.

Until these questions are answered, Truthan asserts, first responders-along with other healthcare workers-should remain in the “high risk factor” for HCV group.

Testing only some members of a department may create a biased population and yield erroneous results as far as the infection rate for the overall department, says Andi Thomas of Hep-C ALERT. “It is difficult to compare the Philadelphia and Miami-Dade rates,” she explains, “when only half of Philadelphia’s firefighters were included in the testing. The Miami-Dade rate applies to 94 percent of the firefighters.” Moreover, the discrepancy in rates between firefighters in Philadelphia and Miami-Dade, Thomas says, “would depend [also] on what happened 10 years ago, when work processes modified.” Fire departments that were more proactive in implementing new safety precautions would have lower infection rates, she adds.

Part 2 presents some suggestions for mounting an offensive against hepatitis C and other infectious diseases and actions some fire departments have taken to protect their members.

Endnotes

The International Association of Fire Chiefs (ICHIEFS) strongly recommends that an overall wellness program include routine liver tests and baseline hepatitis C testing. This is underscored in the ICHIEFS and IAFF Joint Wellness Fitness Program, available on request from ICHIEFS, 4025 Fair Ridge Dr., Fairfax, VA 22033-2868, or it may be downloaded from the IAFF Web site: http://www.iaff.com (select “health & safety” and then “fitness & wellness”).
The complete CDC report, “Hepatitis C Virus Infection Among Firefighters, Emergency Medical Technicians, and Paramedics-Selected Locations, United States, 1991-2000,” July 28, 2000/49(29); 660-5, is z .

Resources

American Liver Foundation
1425 Pompton Avenue
Cedar Grove, NJ 07009-1000
(800) 223-0179

Centers for Disease Control and Prevention (CDC)
Hepatitis Branch, (888) 443-7232, (4HEPCDC)
http://www.cdc.gov/ncidod/diseases/hepatitis/C/index.htm http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4929a3.htm

Charles E. Truthan, D.O., FACOFP
F.D. DocT, P.C. and Fire Doc Services, Inc.
(616) 940-3042
http://www.FD-DC.com e-mail: info@FD-Doc.com

Frontline Healthcare Workers Safety Foundation
http://www.frontlinefoundation.org

Hepatitis Foundation International
30 Sunrise Terrace
Cedar Grove, NJ 07009-1423
(800) 891-0707

Hep-C ALERT
Hollywood, FL (954) 920-5277, ex. 101
http://www.hep-c-alert.org

Katherine West, BSN, MSEd, CIC infection control consultant in Manassas, VA
(703) 365-8388, e-mail: info@ic-ec.com.

National Digestive Diseases Information Clearinghouse
(301) 654-3810

National Hepatitis C Coalition, Inc.
Smyrna, TN 37167 HepLine (615) 355-8604
support@nationalhepatitis-c.org

National Institute of Health
http://www.niaid.nih.gov/information/search.htm

Occupational Safety and Health Administration
http://www.osha-slc.gov/SLTC/needlestick/index.html

Surgeon General David Satcher’s Hepatitis C Campaign
http://www.surgeongeneral.gov/topics/hepatitiscdefault.htm

Hepatitis C: Some General Information

Hepatitis C (HCV) is a viral infection that inflames, injures, and ultimately scars the liver. It is a chronic disease caused by a bloodborne pathogen. It affects four to five times as many Americans as HIV.

Symptoms are usually milder than those of acute hepatitis B infection; many infected people do not know they have the disease until many years after the exposure. Often, the initial symptoms are mild and flu-like. No vaccine is available for hepatitis C. Drug therapies are available. Early detection is essential to preventing serious liver disease.

Hepatitis C is transmitted through (not in order of risk)

blood-to-blood contact;
blood transfusions (8 to 10 percent before 1990; less than 0.5 percent after 1990);
surgery, and medical treatment, such as dialysis;
intranasal use of cocaine;
intravenous drug use;
needlestick (sharps) accidents;
organ transplant (rare);
sexual transmission;
sharing sharp instruments (scissors, razors); and
tattooing and body piercing.

The International Association of Fire Fighters has a film on hepatitis C that is being made available to its affiliates. The National Volunteer Fire Council (NVFC), in partnership with Schering/Oncology Biotech, was producing, at press time, an educational video on hepatitis C in the public safety community. For additional information contact Heather Schafer, NVFC, at (1-888)-ASK-NVFC (275-6832).

Understanding the CDC Study Data

By Katherine West, BSN, MSEd, CIC-Looking at the study data (confirmatory tests results as well as initial screening tests) for the Anne Arundel County (MD) Fire Department (2.2 percent) and the Atlanta (GA) Fire Department (2.1 percent), which were first published in 1995, and the CDC infection rate of 3.0 percent rate for the Philadelphia Fire Department, it looks as though the risk for emergency responders is greater than that for the national population (1.8 percent). However, that is not the case when the numbers are adjusted for age group. Nationally, in the 20- to 59-year age group, the rate of positive test results is 3.7 percent, which is higher than the three rates in these fire department studies. The numbers are within the expected rate (one to four percent) for positive responses in health care workers. The testing information of the departments and the state of Connecticut reported in the CDC July 28 report further support these data (see Table 1).

Study after study shows that the risk for infection in health care is related to sharps injuries; 80 percent of health-care worker exposures have been shown to be related to sharps injuries. Transmission of HCV is related to large or repeated percutaneous exposures. That is the reason the Occupational Safety and Health Administration (OSHA) requires the use of needle-safe devices in providing health care.

The CDC recommends that testing be done following an exposure to blood. If an exposure occurs, the exposed emergency worker should be baseline tested for HCV; the results should be recorded. A positive result indicates that the infection is not related to this particular reported exposure. If the test result is negative, and the source patient tests positive, the department member should be tested for antibody to HCV and have an ALT (liver study) performed. Retesting by hepatitis C-RNA four to six weeks later will determine if the provider had acquired the disease as a result of the exposure.

What Should a Screening Test Program Include?

The HCV virus is transmitted blood-to-blood and is also a sexually transmitted disease. Testing for baseline on hire does not eliminate the possibility that an individual may acquire the disease as the result of off-duty activities. HCV infection is a protected disability under the Americans with Disabilities Act: You must obtain consent for testing, and confidentiality of test results must be maintained.

The screening test program should have the following characteristics:

It must be comprehensive and address all aspects for a formal program, including these considerations: What is the next step if someone tests positive? Who will be responsible for additional costs? How will we handle/store/protect sensitive/personal information?
List the pros and cons associated with such a program: consideration of the CDC recommendations, legal considerations, and cost factors.
Establish a working committee to formulate a program. You are at high risk for liability if you do not have a formal plan in place.

Include the following components in your plan:
making available appropriate information on HCV,
a referral process for additional medical care and treatment,
access to mental health professionals and support groups,
two-step testing by an accredited laboratory,
ensured confidentiality of test results,
cost projections and allocation, and
consent forms developed with legal input.

Reference: “What the fire chief needs to know,” On Scene, International Association of Fire Chiefs, September 2000. Printed with permission.

MARY JANE DITTMAR is associate editor of Fire Engineering. Prior to joining the Fire Engineering staff 10 years ago, she had served as editor of a trade journal in the health/nutrition industry and headed MJD Promotional Services. She has a bachelor’s degree in English/journalism and a master’s in communications arts.